Method to treat gastric reflux via the detection and ablation of gastro-esophageal nerves and receptors

ABSTRACT

The present invention comprises a method of treating a sphincter that provides a sphincter electropotential mapping device with at least one of a mapping electrode or a treatment electrode. The sphincter electropotential mapping device is introduced into at least a portion of the sphincter, the lower esophageal sphincter, stomach, the cardia or the fundus. Bioelectric activity causing a relaxation of the sphincter is detected and energy is delivered from either the mapping electrode or the treatment electrode to treat the bioelectric activity. 
     In another embodiment of the method of the invention, a method of treating a sphincter that provides a sphincter electropotential mapping device with at least one of a mapping electrode or a treatment electrode. The sphincter electropotential mapping device is introduced into at least a portion of the sphincter, the lower esophageal sphincter, stomach, the cardia or the fundus. The sphincter, lower esophageal sphincter, stomach, cardia or fundus is stimulated to produce a transient relaxation of the sphincter. The portion of the sphincter, lower esophageal sphincter, stomach, cardia or fundus causing a relaxation of the sphincter is indentified. Energy is delivered from the sphincter electropotential mapping device to treat the portion the sphincter, lower esophageal sphincter, stomach, cardia or fundus causing the transient relaxation of the sphincter.

CROSS-RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.09/410,448, filed Oct. 1, 1999, now U.S. Pat. No. 6,405,732 and entitled“Method to Treat Gastric Reflux via the Detection and Ablation ofGastro-Esophageal Nerves and Receptors,” which is a continuation-in-partof U.S. patent application Ser. No. 09/026,086 filed Feb. 19, 1998, nowU.S. Pat. No. 6,006,755, and is related to U.S. patent application Ser.No. 09/007,238, filed Jan. 14, 1998, now abandoned all of which areincorporated by reference.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention relates generally to a method to treat gastroesophagealreflux, and more particularly the detection and ablation and/or necrosisof gastroesophageal nerves and receptors causing transient relaxation ofthe lower esophageal sphincter and gastroesophageal reflux.

2. Description of Related Art

Gastroesophageal reflux disease (GERD) is a common gastroesophagealdisorder in which the stomach contents are ejected into the loweresophagus due to a dysfunction of the lower esophageal sphincter (LES).These contents are highly acidic and potentially injurious to theesophagus resulting in a number of possible complications of varyingmedical severity. The reported incidence of GERD in the U.S. is as highas 10% of the population (Castell D O; Johnston B T: GastroesophagealReflux Disease: Current Strategies For Patient Management. Arch Fam Med,5(4):221-7; (1996 April)).

Acute symptoms of GERD include heartburn, pulmonary disorders and chestpain. On a chronic basis, GERD subjects the esophagus to ulcerformation, or esophagitis and may result in more severe complicationsincluding esophageal obstruction, significant blood loss and perforationof the esophagus. Severe esophageal ulcerations occur in 20-30% ofpatients over age 65. Moreover, GERD causes adenocarcinoma, or cancer ofthe esophagus, which is increasing in incidence faster than any othercancer (Reynolds J C: Influence Of Pathophysiology, Severity, And CostOn The Medical Management Of Gastroesophageal Reflux Disease. Am JHealth Syst Pharm, 53(22 Suppl 3):S5-12 (1996 Nov. 15)).

The lower esophageal sphincter is a thickened ring of smooth muscle atthe lower end of the esophagus. Normally, the LES is in a state ofcontraction and functions to keep the acid contents of the stomach fromrefluxing into the esophagus. In a healthy person the muscle relaxesonly during swallowing to allow food to pass and also on average threeto four times and hour in phenomenon known as transient lower esophagealsphincter relaxation (TLESR). In a person suffering from GERD, thefrequency of TLSER is much higher rising as high as eight or more timesand hour.

Since the resting tone of the LES is maintained by both myogenic(muscular) and neurogenic (nerve) mechanisms, some believe that abnormalor aberrant electrical signals in the lower esophageal sphincter orsurrounding region of the stomach including the cardia can cause thesphincter to spontaneously relax. Such signals may cause a higher thannormal frequency of TLESRs allowing acidic stomach contents to berepeatedly ejected into the esophagus and cause the complicationsdescribed above. Research has shown that unnatural electrical signals inthe stomach and intestine can cause reflux events in those organs (KellyK A, et al: Duodenal-gastric Reflux and Slowed Gastric Emptying byElectrical Pacing of the Canine Duodenal Pacesetter Potential.Gastroenterology. 1977 March; 72(3): 429-433). In particular, medicalresearch has found that sites of aberrant electrical activity orelectrical foci may be responsible for those signals (Karlstrom L H, etal: Ectopic Jejunal Pacemakers and Enterogastric Reflux after RouxGastrectomy: Effect Intestinal Pacing. Surgery. 1989 September; 106(3):486-495). Similar aberrant electrical sites in the heart, which causecontractions of the heart muscle to take on life threatening patterns ordysrhythmias, can be identified and treated using mapping and ablationdevices as described in U.S. Pat. No. 5,509,419. However, there is nocurrent device or associated medical procedure available for theelectrical mapping and treatment of aberrant electrical sites in the LESand stomach as a means for treating GERD.

GERD is believed to be caused by a combination of conditions thatincrease the presence of acid reflux in the esophagus. These conditionsinclude transient LES relaxation, decreased LES resting tone, impairedesophageal clearance, delayed gastric emptying, decreased salivation,and impaired tissue resistance.

Current drug therapy for GERD includes histamine receptor blockers whichreduce stomach acid secretion and other drugs which may completely blockstomach acid. However, while pharmacologic agents may provide short termrelief, they do not address the underlying cause of LES dysfunction.

Invasive procedures requiring percutaneous introduction ofinstrumentation into the abdomen exist for the surgical correction ofGERD. One such procedure, Nissen fundoplication, involves constructing anew “valve” to support the LES by wrapping the gastric fundus around thelower esophagus. Although the operation has a high rate of success, itis an open abdominal procedure with the usual risks of abdominal surgeryincluding: postoperative infection, herniation at the operative site,internal hemorrhage and perforation of the esophagus or of the cardia.In fact, a recent 10 year, 344 patient study reported the morbidity ratefor this procedure to be 17% and mortality 1% (Urschel, J D:Complications Of Antireflux Surgery, Am J Surg 166(1): 68-70; (1993July)). This rate of complication drives up both the medical cost andconvalescence period for the procedure and may exclude portions ofcertain patient populations (e.g., the elderly and immuno-compromised).

Efforts to perform Nissen fundoplication by less invasive techniqueshave resulted in the development of laparoscopic Nissen fundoplication.Laparoscopic Nissen fundoplication, reported by Dallemagne et al.Surgical Laparoscopy and Endoscopy, Vol. 1, No. 3, (1991), pp. 138-43and by Hindler et al. Surgical Laparoscopy and Endoscopy, Vol. 2, No. 3,(1992), pp. 265-272, involves essentially the same steps as Nissenfundoplication with the exception that surgical manipulation isperformed through a plurality of surgical cannula introduced usingtrocars inserted at various positions in the abdomen.

Another attempt to perform fundoplication by a less invasive techniqueis reported in U.S. Pat. No. 5,088,979. In this procedure aninvagination device containing a plurality of needles is insertedtransorally into the esophagus with the needles in a retracted position.The needles are extended to engage the esophagus and fold the attachedesophagus beyond the gastroesophageal junction. A remotely operatedstapling device, introduced percutaneously through an operating channelin the stomach wall, is actuated to fasten the invaginatedgastroesophageal junction to the surrounding involuted stomach wall.

Yet another attempt to perform fundoplication by a less invasivetechnique is reported in U.S. Pat. No. 5,676,674. In this procedure,invagination is done by a jaw-like device and fastening of theinvaginated gastroesophageal junction to the fundus of the stomach isdone via a transoral approach using a remotely operated fasteningdevice, eliminating the need for an abdominal incision. However, thisprocedure is still traumatic to the LES and presents the postoperativerisks of gastroesophageal leaks, infection and foreign body reaction,the latter two sequela resulting when foreign materials such as surgicalstaples are implanted in the body.

While the methods reported above are less invasive than an open Nissenfundoplication, some still involve making an incision into the abdomenand hence the increased morbidity and mortality risks and convalescenceperiod associated with abdominal surgery. Others incur the increasedrisk of infection associated with placing foreign materials into thebody. All involve trauma to the LES and the risk of leaks developing atthe newly created gastroesophageal junction. None provide a means fordetecting and treating aberrant electrical sites causing abnormal LESrelaxation and gastroesophageal reflux.

There is a need to provide a method to detect and treat aberrantbioelectric activity of a sphincter and/or a stomach includingmyoelectric activity. There is another need to provide a method todetect and treat an electrical foci of the aberrant bioelectric activityof a sphincter and/or a stomach. There is a further need to detect andtreat an electrically conductive pathway of the aberrant bioelectricactivity of a sphincter and/or a stomach.

SUMMARY OF THE INVENTION

Accordingly, an object of the invention is to provide a method todiagnose and treat sphincters and/or a stomach.

Another object of the invention is to provide a method to diagnose andtreat gastroesophageal reflux disease.

A further object of the invention is to provide a method to detect andtreat bioelectrical activity of a sphincter and/or a stomach causingtransient relaxation of the lower esophageal sphincter.

Yet another object of the invention is to provide a method to detect andtreat electrically conductive pathways of bioelectrical activity in asphincter and/or a stomach causing transient relaxation of the loweresophageal sphincter.

Still a further object of the invention is to provide a method to detectand treat a nerve pathway in a sphincter and/or a stomach causingtransient relaxation of the lower esophageal sphincter.

Another object of the invention is to provide a method to detect andtreat a nerve pathway in a sphincter and/or a stomach causing transientrelaxation of the lower esophageal sphincter while preserving aswallowing reflex

A further object of the invention is to provide a method to detect andtreat a receptor pathway in a sphincter and/or a stomach causingtransient relaxation of the lower esophageal sphincter.

Yet a further object of the invention is to provide a method to createan area of electrical block to bioelectric activity of the loweresophageal sphincter and/or stomach causing transient relaxation of thelower esophageal sphincter.

These and other objects of the invention are provided in a method oftreating a sphincter that provides a sphincter electropotential mappingdevice with at least one of a mapping electrode or a treatmentelectrode. The sphincter electropotential mapping device is introducedinto at least a portion of the sphincter, the lower esophagealsphincter, stomach, the cardia or the fundus. Bioelectric activitycausing a relaxation of the sphincter is detected and energy isdelivered from either the mapping electrode or the treatment electrodeto treat the bioelectric activity.

In another embodiment, a method of treating a sphincter that provides asphincter electropotential mapping device with at least one of a mappingelectrode or a treatment electrode. The sphincter electropotentialmapping device is introduced into at least a portion of the sphincter,the lower esophageal sphincter, stomach, the cardia or the fundus. Thesphincter, lower esophageal sphincter, stomach, cardia or fundus isstimulated to produce a transient relaxation of the sphincter. Theportion of the sphincter, lower esophageal sphincter, stomach, cardia orfundus causing a relaxation of the sphincter is indentified. Energy isdelivered from the sphincter electropotential mapping device to treatthe portion the sphincter, lower esophageal sphincter, stomach, cardiaor fundus causing the transient relaxation of the sphincter.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is an illustrated lateral view of the upper GI tract includingthe esophagus and lower esophageal sphincter, cardia and fundus.

FIG. 2A is an illustrated lateral view of the upper GI tract includingthe esophagus and lower esophageal sphincter and the positioning of thesphincter mapping and treatment apparatus in an embodiment of the methodof the present invention.

FIG. 2B is a lateral view of an apparatus, useful with the method of thepresent invention, illustrating the energy delivery device, powersource, controllers, map, display device, and the mapping assembly in anexpanded and contracted state.

FIG. 3 depicts a lateral view of an apparatus, useful with the method ofthe present invention that illustrates components on the flexible shaftincluding a proximal fitting, connections and proximal and distal shaftsegments.

FIG. 4A illustrates a lateral view of the basket assembly used in anembodiment of the method of the present invention.

FIG. 4B is a lateral view that illustrates placement of the mappingelectrodes on the basket assembly and their electrical connections tothe controller.

FIG. 5A is a lateral view of the basket assembly that illustrates therange of camber in the basket assembly.

FIG. 5B is a perspective view illustrating a balloon coupled to thebasket assembly.

FIG. 6A is a lateral view of the junction between the basket arms andthe shaft illustrating the pathway used for advancement of a movablewire or the delivery of fluids.

FIG. 6B is a frontal view of a basket arm in an alternative embodimentof an apparatus, useful with the method of the present invention,illustrating a track in the arm used to advance the movable wire.

FIG. 7 is a cross-sectional view of a section of the basket armillustrating stepped and tapered sections in basket arm apertures.

FIG. 8 is a lateral view of the basket assembly illustrating theplacement of the radial supporting member.

FIG. 9A is a lateral view of the sphincter mapping and treatmentapparatus illustrating the mechanism used in one embodiment of anapparatus, useful with the method of the present invention, to increasethe camber of the basket assembly.

FIG. 9B is a similar view to 9A showing the basket assembly in anincreased state of camber.

FIG. 10 is a lateral view of the sphincter mapping and treatmentapparatus, useful with the method of the present invention, illustratingthe deflection mechanism.

FIG. 11A is a lateral view illustrating the use of electrolytic solutionto create an enhanced RF electrode.

FIGS. 11B-11C are lateral views illustrating the use of nerves toconduct RF energy to a desired tissue site.

FIG. 12 is a lateral view of the basket assembly illustrating the use ofneedle electrodes.

FIG. 13 is a lateral view illustrating the use of an insulation segmenton the needle electrode to protect an area of tissue from RF energy.

FIGS. 14A and 14B are lateral views illustrating the placement of needleelectrodes into the sphincter wall by expansion of the basket assembly.

FIG. 15 is a lateral view illustrating placement of needle electrodesinto the sphincter wall by advancement of an electrode delivery memberout of apertures in the basket arms.

FIG. 16 is a cross sectional view illustrating the configuration of abasket arm aperture used to select and maintain a penetration angle ofthe needle electrode into the sphincter wall.

FIG. 17 is a lateral view illustrating placement of needle electrodesinto the sphincter wall by advancement of an electrode delivery memberdirectly out of the distal end of the shaft.

FIG. 18A is a lateral view illustrating a radial distribution ofelectrodes on the expandable mapping assembly of an apparatus usefulwith the method of the present invention.

FIG. 18B is a lateral view illustrating a longitudinal distribution ofelectrodes on the expandable mapping assembly useful with the method ofthe present invention.

FIG. 18C is a lateral view illustrating a spiral distribution ofelectrodes on the expandable mapping assembly useful with the method ofthe present invention.

FIG. 18D is a lateral view illustrating a radial-longitudinaldistribution of electrodes on the expandable mapping assembly usefulwith the method of the present invention.

FIG. 19 is a flow chart illustrating the sphincter treatment method ofthe current invention.

FIG. 20 is a lateral view of sphincter smooth muscle tissue illustratingelectromagnetic foci and pathways for the origination and conduction ofaberrant electrical signals in the smooth muscle of the lower esophagealsphincter or other tissue.

FIG. 21 is a lateral view of a sphincter wall illustrating theinfiltration of tissue healing cells into a lesion in the smooth tissueof a sphincter following treatment with the sphincter treatmentapparatus.

FIG. 22 is a view similar to that of FIG. 21 illustrating shrinkage ofthe lesion site caused by cell infiltration.

FIG. 23 is a lateral view of the esophageal wall illustrating thepreferred placement of lesions in the smooth muscle layer of aesophageal sphincter.

FIG. 24 is a lateral view illustrating an ultrasound transducer,ultrasound lens and power source of an embodiment useful with the methodof the present invention.

FIGS. 25A-D are lateral views of the sphincter wall illustrating variouspatterns of lesions created in an embodiment of the method of thepresent invention.

FIGS. 25E-F are lateral views of the sphincter wall illustrating the useof lesions to create an area of electrical block to bioelectricalsignals including those causing TLSERS.

FIG. 25G is a lateral view of the stomach illustrating the variousshapes of areas of electrical block to bioelectrical signals.

FIG. 26 is a lateral view of the sphincter wall illustrating thedelivery of cooling fluid to the electrode-tissue interface and thecreation of cooling zones.

FIG. 27 depicts the flow path, fluid connections and control unitemployed to deliver fluid to the electrode-tissue interface.

FIG. 28 depicts the flow path, fluid connections and control unitemployed to deliver fluid to the RF electrodes.

FIG. 29 is an enlarged lateral view illustrating the placement ofsensors on the expansion device or basket assembly.

FIG. 30 depicts a block diagram of the feed back control system that canbe used with the sphincter mapping and treatment apparatus.

FIG. 31 depicts a block diagram of an analog amplifier, analogmultiplexer and microprocessor used with the feedback control system ofFIG. 30.

FIG. 32 depicts a block diagram of the operations performed in thefeedback control system depicted in FIG. 30.

FIG. 33 depicts a block diagram of the signal processing system that canbe used with the sphincter mapping and treatment apparatus.

FIG. 34 depicts a block diagram of the transdermal signal stimulationsystem that can be used with the sphincter mapping and treatmentapparatus.

FIG. 35 depicts a block diagram of an embodiment of a signal stimulationsystem that can be used to evoke and monitor a swallowing reflex withone embodiment of the sphincter mapping and treatment apparatus.

DETAILED DESCRIPTION

FIG. 1 depicts the anatomy of the lower esophageal sphincter (LES) 5 andsurrounding structures. The LES 5 consists of a thickened ring-likestructure of smooth muscle at the junction between the esophagus 6 andthe stomach 7. The muscles of the LES 5 consist of both circumferentialand longitudinal oriented muscle. Normally, the LES 5 is in a state ofcontraction, and functions to keep the acidic contents of the stomachfrom refluxing into the esophagus (via the generation of a pressure of20-30 mm hg over stomach pressure). However during swallowing and alsoevery three to four times and hour the LES relaxes for several secondsor longer in a phenomena known as transient lower esophageal sphincterrelaxation (TLESR). In a person suffering from GERD, the frequency ofTLSER is much higher rising as high as eight or more times in an hour.

The LES 5 is enervated with autonomic nerve fibers 8 that performseveral functions. These include maintaining a resting tone to keep theLES in a state of contraction; and relaxing the LES to allow swallowing,accommodate pressure increases in the stomach and a to initiate TLESRs.The nerve fibers include efferent fibers 8″ going from the brain and/orthe upper esophagus 6′ to the LES and afferent fibers 8′ going fromportions of the stomach to the LES as well as from the LES to the brain.Efferent fibers 8″ include vagus nerves, while afferent nerve fibers 8′include those leading from gastric receptors 9 such as themechanoreceptors 9′ and chemoreceptors 9″ through the cardia 7′ to theLES. Stimulation from one or both of these receptors 9, (due tostretching of stomach from ingested food, or a change in stomach pH) isthought to be a possible cause of LES relaxation. Therefore oneembodiment of the invention described herein for treating GERD involvesthe ablation and/or electrical block of the nerve fibers and or pathwaysleading from gastric receptors 9 including the mechanoreptors 9′ andchemoreptors 9″ to the LES 5. In various embodiments, the blockage canbe achieve by ablating the fibers 8 and/or receptors 9 via theapplication of heat and/or ablative agents (e.g. ethanol, quinolinicacid, glutamate, botoxin or other neurotoxin known in the art) toattenuate and/or eliminate the nerve impulse going from these receptorsto the LES or surrounding structures. The electrical block or ablationcan be done anywhere along the pathway from the receptor to the LES butin a preferred embodiment, the ablation is done in or near the cardiaand/or LES. In various embodiments, the block is achieved by thedelivery of energy in the form of heat to create lesions at or near thedesired nerve pathway or receptor. In embodiments using electromagneticenergy (eg. electrical, RF and the like) described herein, the nervepathway itself can be used as conduit to deliver ablative energy to thetarget treatment site. In various embodiments, the block can be achievedwithout injury of or damage of nerves involved in the swallowing reflexincluding the vagus and other efferent nerves 8″. This can be achievedvia the use of cooling and other means described herein. In anotherembodiment, this is accomplished through the use of a signal stimulationdevice/means described here in, to induce and monitor the presence ofthe swallowing reflex before during or after the delivery of energy tothe treatment site 12.

FIG. 2A depicts one embodiment of a sphincter mapping and treatmentapparatus 10 that is used to both map and treat gastric bioelectricactivity causing transient relaxation of the sphincter and subsequentgastroesophageal reflux. Specifically, apparatus 10 delivers energy to atreatment site 12 to produce lesions 14 in a sphincter 16, such as thelower esophageal sphincter 5. Apparatus 10 comprises a flexibleelongated shaft 18, also called shaft 18 or catheter 18, coupled to anexpandable mapping assembly 20, in turn coupled with one or more mappingelectrodes 22 which can also serve as treatment electrodes 22 capable ofdelivering energy to treatment site 12.

Expandable mapping assembly 20 establishes a three dimensional array ofmapping electrodes 22. In use, the expandable mapping assembly 20records the activation times, the distribution, and the waveforms of themyoelectric or neuroelectric action potentials in sphincter 16, such asthe LES 5 and adjoining structures that trigger aberrant and/ortransient relaxation of smooth muscle tissue in the sphincter or LES.Suitable materials for mapping electrodes 22 include gold, platinum,silver, copper and alloys and combinations thereof, as well as otherconductors known to those skilled in the art.

Referring now to FIG. 2 a and FIG. 2 b, mapping electrodes 22 areconfigured to be coupled to a controller 24. Controller 24 receives andprocesses the potentials recorded by the mapping electrodes 22 onexpandable mapping assembly 20 and produces an electropotential map 27,also called a map 27, of the bioelectric signals 17, includingmyoelectric and neuroelectric signals 17, in sphincter 16. Controller 24and electropotential map 27 are used by the physician to diagnoseabnormalities and pathologies within sphincter 16 and adjoiningstructures which will be further discussed herein. Controller 24 can becoupled to an output or display device 29 that can include a cathode raytube, liquid crystal display, passive or active matrix flat screendisplay or printer and the like.

Myoelectric and neuroelectric signals 17 can include nerve actionpotentials: both efferent and afferent; and depolarization signals insmooth and skeletal muscle.

Expandable mapping assembly 20 has a central longitudinal axis 28 and ismoveable between contracted and expanded positions substantially therealong. This can be accomplished by a ratchet mechanism and the like asis known to those skilled in the art and by the use of other mechanismsdisclosed herein. The expandable mapping assembly 20 is furtherconfigured to be positionable in a sphincter 16 such as the LES oradjacent anatomical structure, such as the cardia 7′ of the stomach.Once positioned within the desired sphincter 16, the operating physiciancauses expandable mapping assembly 20 to expand to an expandedstationary position within the sphincter so that mapping electrodes 22thereof engage sphincter wall 26 for sensing and detecting electricalenergy or impulses therefrom. At least portions of sphincter mapping andtreatment apparatus 10 may be sufficiently radiopaque in order to bevisible under fluoroscopy and/or sufficiently echogenic to be visibleunder ultrasonography. Also, as will be discussed herein, sphinctermapping and treatment apparatus 10 can include visualization capabilityincluding, but not limited to, a viewing scope, an expanded eyepiece,fiber optics, video imaging and the like.

Referring now to FIG. 2B, shaft 18 is configured to be coupled toexpandable mapping assembly 20 and has sufficient length to positionexpandable mapping assembly 20 in the LES and/or stomach using atransoral approach. Typical lengths for shaft 18 include, but are notlimited to, a range of 40-180 cm. In various embodiments, shaft 18 isflexible, articulated and steerable and can contain fiber optics(including illumination and imaging fibers), fluid and gas paths, andsensor and electronic cabling. In one embodiment, shaft 18 can be amulti-lumen catheter, as is well known to those skilled in the art.

In another embodiment of the invention, an introducing member 21, alsocalled an introducer, is used to introduce sphincter mapping andtreatment apparatus 10 into the LES including transoral introductionthrough the mouth and the throat. Introducer 21 can also function as asheath for expandable mapping assembly 20 to keep it in a nondeployed orcontracted state during introduction into the LES. In variousembodiments, introducer 21 is flexible, articulated and steerable, andcontains a continuous lumen of sufficient diameter to allow theadvancement of sphincter mapping and treatment apparatus 10 within.Typical diameters for introducer 21 include 0.1 to 2 inches, whiletypical length include 40-180 cm. Suitable materials for introducer 21include wire-reinforced plastic tubing as is well known to those skilledin the art. Alternatively, the catheter 18 may be deployed over a guidewire through the patient's mouth and pharynx, and into the esophaguswithout use of an introducer 21. Still alternatively, catheter 18 may bepassed through the patient's mouth and pharynx, and into the esophaguswithout use of either a guide wire or introducer.

Referring now to FIGS. 3, 4A and 4B, the flexible elongate shaft 18 iscircular in cross section and has proximal and distal extremities (alsocalled ends) 30 and 32. Shaft 18 may also be coupled at its proximal end30 to a proximal fitting 34, also called a handle, used by the physicianto manipulate sphincter mapping and treatment apparatus 10 to reachtreatment site 12. Shaft 18 may have one or more shaft lumens 36 thatextend the full length of shaft 18, or part way from shaft proximal end30 to shaft distal end 32. Shaft lumens 36 may be used as paths forcatheters, guide wires, pull wires, insulated wires and cabling, fluidand optical fibers. Shaft lumens 36 are connected to and/or accessed byconnections 38, also called connector 38, on or adjacent to proximalfitting 34. Connections 38 can include luer-lock, swage and othermechanical varieties well known to those skilled in the art. Connections38 can also include electrical connections 38′ which can includelemo-connectors, micro connectors and other electrical varieties wellknown to those skilled in the art. Additionally, connectors 38 caninclude opto-electronic connections 38″ which allow optical andelectronic coupling of optical fibers and/or viewing scopes toilluminating sources, eye pieces, video monitors and the like. Invarious embodiments, shaft 18 may stop at the proximal extremity 40 ofexpandable mapping assembly 20 or extend to, or past, the distalextremity 42 of expandable mapping assembly 20. Suitable materials forshaft 18 include, but are not limited to, polyethylenes, polyurethanes,Pebax®, polyimides, nylons, copolymers thereof and other medicalplastics known to those skilled in the art.

Referring now to FIG. 4A, in one embodiment of the present invention,expandable mapping assembly 20 comprises one or more elongated arms 44that are joined at their proximal arm ends 46 and distal arm ends 48 toform a basket assembly 50. Proximal arm end 46 is attached to asupporting structure, which can be the distal end 32 of shaft 18 or aproximal cap 51. Likewise, distal arm end 48 is also attached to asupporting structure which can be a distal basket cap 52 or shaft 18.Attached arms 44 may form a variety of geometric shapes including, butnot limited to, curved, rectangular, trapezoidal and triangular. Arms 44can have a variety of cross sectional geometries including, but notlimited to, circular, rectangular and crescent-shaped. Also, arms 44 areof a sufficient number (two or more), and have sufficient spring force(0.01 to 0.5 lbs. force ) so as to collectively exert adequate force onsphincter wall 26 to sufficiently open and efface the folds of sphincter16 to allow treatment with sphincter mapping and treatment apparatus 10,while preventing herniation of sphincter wall 26 into the spaces 53between arms 44. Suitable materials for arms 44 include, but are notlimited to, spring steel, stainless steel, superelastic shape memorymetals such as nitinol or wire-reinforced plastic tubing as is wellknown to those skilled in the art. Also, arms 44 can be configured tohave a selectable spring constant for parallel or perpendiculardeflection to the longitudinal axis 28 of arm 44.

Referring now to FIG. 4B, a plurality of spaced apart mapping electrodes22 are carried by each arm 44 for engaging sphincter wall 26 and areelectrically coupled by a conductor 23 to a multiplexer chip 25 fortransmitting signals sensed thereby to controller 24 via electricalconnections 38′. Various geometric patterns for placement of mappingelectrodes 22 on basket assembly 50 or expandable mapping assembly 20are disclosed later herein. Multiplexor chip 25 transmits only aselected one of the electrode signals at a time to the controller 24,subject to switching signals that controller 24 generates. The switchingsignals of controller 24 serve to multiplex the electrode signalsthrough electrical connector 38′. This reduces the number of electricalpathways required through shaft lumen 36. In various embodiments,conductor 23 can be an insulated lead wire as is well known to thoseskilled in the art.

In various embodiments, expandable mapping assembly 20 or basketassembly 50 may also be coupled to one or more energy delivery devices88, also called electrodes, coupled to power source 56. Energy deliverydevices 88 are used to delivery energy to treatment site 12 to producelesions 14. Expandable mapping assembly 20 is further configured tofacilitate the positioning of energy delivery devices 88, to aselectable depth in a sphincter wall 26 or adjoining anatomicalstructure. In one embodiment mapping electrodes 22 can also be used asenergy delivery devices.

Referring to FIG. 5A, arms 44 can have an outwardly bowed shaped memoryfor expanding the basket assembly into engagement with sphincter wall 26with the amount of bowing, or camber 54 being selectable from a range 0to 2 inches from longitudinal axis 28 of basket assembly 50. For thecase of a curve-shaped arm 44′, expanded arms 44′ are circumferentiallyand symmetrically spaced-apart.

In another embodiment shown in FIG 5B, an expansion device 55, which canbe a balloon, is coupled to an interior or exterior of basket assembly50. Balloon 55 is also coupled to and inflated by shaft lumen 36 usinggas or liquid. In various other embodiments (not shown), arms 44 may beasymmetrically spaced and/or distributed on an arc less than 360. Also,arms 44 may be preshaped at time of manufacture or shaped by thephysician.

Referring now to FIG. 6A, arms 44 may also be solid or hollow with acontinuous lumen 58 that may be coupled with shaft lumens 36. Thesecoupled lumens provide a path for the delivery of a fluid or electrodedelivery member 60 from shaft 18 to any point on expandable mappingassembly 20. In various embodiments electrode delivery member 60 can bean insulated wire, an insulated guide wire, a plastic-coated stainlesssteel hypotube with internal wiring or a plastic catheter with internalwiring, all of which are known to those skilled in the art. As shown inFIG. 6B, arms 44 may also have a partially open channel 62, also calleda track 62, that functions as a guide track for electrode deliverymember 60. Referring back to FIG. 6A, arms 44 may have one or moreapertures 64 at any point along their length that permit the controlledplacement of electrodes 88 at or into sphincter wall 26. Referring nowto FIG. 7, apertures 64 may have tapered sections 66 or stepped sections68 in all or part of their length, that are used to control thepenetration depth of electrodes 88 into sphincter wall 26. Referringback to FIG. 6A, apertures 64 in combination with arm lumens 58 andshaft lumens 36 may be used for the delivery of a cooling solution 70 orelectrolytic solution 72 to treatment site 12 as described herein.Additionally, arms 44 can also carry a plurality of longitudinally orradially spaced apart radiopaque and or echogenic markers or traces, notshown in the drawings, formed of suitable materials to permit viewing ofbasket assembly 50 via fluoroscopy, ultrasonography and the like.Suitable radiopaque materials include platinum or gold, while suitableechogenic materials include gas filled micro-particles as described inU.S. Pat. Nos. 5,688,490 and 5,205,287. Arms 44 may also be color-codedto facilitate their identification via visual medical imaging methodsand equipment, such as endoscopic methods, which are well known to thoseskilled in the art.

In another embodiment of the present invention, a radial supportingmember 74 (also called a strut 74) is attached to two or more arms 44.Radial supporting member 74 can be attached to arms 44 along acircumference of basket assembly 50 as shown in FIG. 8. Apertures 64 canextend through radial supporting member 74 in one or more places. Radialsupporting member 74 serves the following functions: i) facilitatesopening and effacement of the folds of sphincter 16, ii) enhancescontact of apertures 64 with sphincter wall 26; and iii) reduces orprevents the tendency of arms 44 to bunch up. The cross sectionalgeometry of radial supporting member 74 can be rectangular or circular,though it will be appreciated that other geometries are equallysuitable.

In one embodiment shown in FIGS. 9A and 9B, arms 44 are attached todistal basket cap 52 that in turn, moves freely over shaft 18, but isstopped distally by shaft cap 78. One or more pull wires 80 are attachedto distal basket cap 52 and also to a movable fitting 82 in proximalfitting 34 of sphincter mapping and treatment apparatus 10. When pullwire 80 is pulled back by movable fitting 82, the camber 54 of basketassembly 50 increases to 54′, increasing the force and the amount ofcontact applied by basket assembly 50 to sphincter wall 26 or anadjoining structure. Basket assembly 50 can also be deflected from sideto side using deflection mechanism 84. This allows the physician toremotely point and steer the basket assembly within the body. In oneembodiment shown in FIG. 10, deflection mechanism 84 includes a secondpull wire 80′ attached to shaft cap 78 and also to a movable slide 86integral to proximal fitting 34.

Turning now to a discussion of energy delivery, suitable power sources56 and energy delivery devices 88 that can be employed in one or moreembodiments of the invention include: (i) a radio-frequency (RF) sourcecoupled to an RF electrode, (ii) a coherent source of light coupled toan optical fiber, (iii) an incoherent light source coupled to an opticalfiber, (iv) a heated fluid coupled to a catheter with a closed channelconfigured to receive the heated fluid, (v) a heated fluid coupled to acatheter with an open channel configured to receive the heated fluid,(vi) a cooled fluid coupled to a catheter with a closed channelconfigured to receive the cooled fluid, (vii) a cooled fluid coupled toa catheter with an open channel configured to receive the cooled fluid,(viii) a cryogenic fluid, (ix) a resistive heating source, (x) amicrowave source providing energy from 915 MHz to 2.45 GHz and coupledto a microwave antenna, (xi) an ultrasound power source coupled to anultrasound emitter, wherein the ultrasound power source produces energyin the range of 300 KHZ to 3 GHz, or (xii) a microwave source. For easeof discussion for the remainder of this application, the power sourceutilized is an RF source and electrode 88 is one or more RF electrodes88. However, all of the other herein mentioned power sources and mappingelectrodes are equally applicable to sphincter mapping and treatmentapparatus 10.

When the power source is an RF energy source, power source 56, whichwill now be referred to as RF power source 56, supplies radio frequencyenergy, e.g., having a frequency in the range of about 400 kHz to about10 mHz. Power source 56 may have multiple channels, deliveringseparately modulated power to each electrode 88. This reducespreferential heating that occurs when more energy is delivered to a zoneof greater conductivity and less heating that occurs around RFelectrodes 88 which are placed into less conductive tissue. If the levelof tissue hydration or the blood infusion rate in the tissue is uniform,a single channel RF power source 56 may be used to provide power forgeneration of lesions 14 relatively uniform in size.

For embodiments using RF energy, RF electrode 88 may operated in eitherbipolar or a monopolar mode with a ground pad electrode. In a monopolarmode of delivering RF energy, a single electrode 88 is used incombination with an indifferent electrode patch 89 (or ground padelectrode) that is applied to the body to form the other electricalcontact and complete an electrical circuit. Bipolar operation ispossible when two or more RF electrodes 88 are used. Multiple RFelectrodes 88 may be used. These electrodes may be cooled as describedherein. RF electrodes 88 can be attached to electrode delivery member 60by the use of soldering methods which are well known to those skilled inthe art. Suitable solders include Megabond Solder supplied by theMegatrode Corporation (Milwaukee, Wis.).

Suitable electrolytic solutions 72 include saline, solutions of calciumsalts, potassium salts, and the like. Electrolytic solutions 72 enhancethe electrical conductivity of the targeted tissue at the treatment site12. When a highly conductive fluid such as electrolytic solution 72 isinfused into tissue the electrical resistance of the infused tissue isreduced, in turn, increasing the electrical conductivity of the infusedtissue. As a result, there will be little tendency for tissuesurrounding electrode 88 to desiccate (a condition described herein thatincreases the electrical resistance of tissue) resulting in a largeincrease in the capacity of the tissue to carry RF energy. Referring toFIG. 11A, a zone of tissue which has been heavily infused with aconcentrated electrolytic solution 72 can become so conductive as toactually act as an enhanced electrode 88′. The effect of enhancedelectrode 88′ is to increase the amount of current that can be conductedto the treatment site 12, making it possible to heat a much greatervolume of tissue in a given time period.

Referring now to FIGS. 11B and 11C, in other embodiments selected nervefibers 8 can be used as an electrode or conduction path to conduct RFenergy to a desired treatment site 12. In these and related embodiments,RF electrode 88 is positioned on or adjacent a nerve fiber 8 (preferablyan afferent fiber 8′) so as to electrically couple the RF electrode tothe nerve fiber. RF energy is then conducted along nerve 8 to create alesion 14 at some selected distance from the RF electrode 88 and orsphincter mucosal surface 16′ of sphincter 16. Preferably this distanceis 1 to 5 mm beneath the surface 16′. Parameters that can be used tocontrol the distance of the lesion include one or more of the following:use of cooling a fluid (e.g. flow rate, temperature etc.), the RF power(e.g. wattage) level delivered to the electrode, duration of powerdelivery and total energy delivered (e.g. joules), nerve type, and nervethickness. The use of nerves 8 to conduct RF energy presents thedistinct advantage of being able to precisely control the delivery ofenergy to a desired treatment site to produce one or more lesions 14 viaohmic heating, while minimizing heating and injury to nearby nonselected tissue 12′. In one embodiment shown in FIG. 11C, energy isdelivered along nerve fiber 8′ to produce a first or distal lesion 14′at distal position relative to the RF electrode 88. More proximal tissuecan be protected via the use of a cooling solution 70 described herein.Continued delivery of RF energy and/or the attenuation of cooling, thenresults in the development of an expanded or second lesion 14″ (whichcan be continuous or contiguous with the first lesion 14′) starting atthe more distal portions of the nerve adjacent the distal lesion 14′with subsequent travel of the lesion in a proximal direction along thenerve 8 to the more proximal portions near or adjacent electrode 88. Inthis way, one or more nerve fibers 8 can be used as an energy conduitand/or extended energy delivery device 88″ to create multiple lesions insphincter 16 including lesions both in submucosal muscle and nervetissue in a single treatment session without having to reposition theenergy delivery device. The creation of such multiple and/or continuousnerve and muscle lesions 14′, 14″ presents the further advantage of bothtightening the sphincter 16 and creating areas of electrical block tominimize and/or eliminate TLSERS in a single delivery of energy and/ortreatment session.

In various embodiments, RF electrodes 88 can have a variety of shapesand sizes. Possible shapes include, but are not limited to, circular,rectangular, conical and pyramidal. Electrode surfaces can be smooth ortextured and concave or convex. The conductive surface area of electrode88 can range from 0.1 mm2 to 100 cm2. It will be appreciated that othergeometries and surface areas may be equally suitable. Other possiblegeometries include curved (forward or retrograde), spiral and oval.

In one embodiment, RF electrodes 88 can be in the shape of needles andof sufficient sharpness and length to penetrate into the smooth muscleof the esophageal wall, sphincter 16 or other anatomical structure. Inthis embodiment shown in FIGS. 12 and 13, needle electrodes 90 areattached to arms 44 and have an insulating layer 92, covering aninsulated segment 94 except for an exposed segment 95. For purposes ofthis disclosure, an insulator or insulation layer is a barrier to eitherthermal, RF or electrical energy flow. Insulated segment 94 is ofsufficient length to extend into sphincter wall 26 and minimize thetransmission of RF energy to a protected site 97 near or adjacent toinsulated segment 94 (see FIG. 13.). Typical lengths for insulatedsegment 94 include, but are not limited to, 1-4 mm. Suitable materialsfor needle electrodes 90 include, but are not limited to, 304 stainlesssteel and other stainless steels known to those skilled in the art.Suitable materials for insulating layer 92 include, but are not limitedto, polyimides and polyamides.

During introduction of sphincter mapping and treatment apparatus 10,basket assembly 50 is in a contracted state. Once sphincter mapping andtreatment apparatus 10 is properly positioned at the treatment site 12,needle electrodes 90 are deployed by expansion of basket assembly 50,resulting in the protrusion of needle electrodes 90 into the smoothmuscle tissue of sphincter wall 26 (refer to FIGS. 14A and 14B). Thedepth of needle penetration is selectable from a range of 0.5 to 5 mmand is accomplished by indexing movable fitting 82 so as to change thecamber 54 of arm 44 in fixed increments that can be selectable in arange from 0.1 to 4 mms. Needle electrodes 90 are coupled to powersource 56 via insulated wire 60.

In another embodiment of sphincter mapping and treatment apparatus 10shown in FIG. 15, needle electrodes 90 are advanced out of apertures 64in basket arms 44 into the smooth muscle of the esophageal wall or othersphincter 16. In this case, needle electrodes 90 are electricallycoupled to RF power source 56 by electrode delivery member 60. In thisembodiment, the depth of needle penetration is selectable via means oftapered sections 66 or stepped sections 68 located in apertures 64.Referring now to FIG. 16, apertures 64 and needle electrodes 90 areconfigured such that the penetration angle 96 (also called an emergenceangle 96) of needle electrode 90 into sphincter wall 26 remainssufficiently constant during the time needle electrode 90 is beinginserted into sphincter wall 26, such that there is no tearing orunnecessary trauma to sphincter wall tissue. This is facilitated by theselection of the following parameters and criteria: i) the emergenceangle 96 of apertures 64 which can vary from 1 to 90°, ii) the arcradius 98 of the curved section 100 of aperture 64 which can vary from0.001 to 2 inch, iii) the amount of clearance between the aperture innerdiameter 102 and the needle electrode outside diameter 103 which canvery between 0.001″ and 0.1″; and, iv) use of a lubricous coating onelectrode delivery member 60 such as a Teflon® or other coatings wellknown to those skilled in the art including liquid silicone coatings.Also in this embodiment, insulated segment 94 can be in the form of asleeve that may be adjustably positioned at the exterior of needleelectrode 90.

In another alternative embodiment shown in FIG. 17, electrode deliverymember 60 with attached needle electrodes 90, can exit from shaft lumen36 at distal shaft end 32 and be positioned into contact with sphincterwall 26. This process may be facilitated by use of a hollow guidingmember 101, known to those skilled in the art as a guiding catheter,through which electrode delivery member 60 is advanced. Guiding catheter101 may also include tapered sections 66 or stepped sections 68 at itsdistal end to control the depth of penetration of needle electrode 90into sphincter wall 26.

RF energy flowing through tissue causes heating of the tissue due toabsorption of the RF energy by the tissue and ohmic heating due toelectrical resistance of the tissue. This heating can cause injury tothe affected cells and can be substantial enough to cause cell death, aphenomenon also known as cell necrosis. For ease of discussion for theremainder of this application, cell injury will include all cellulareffects resulting from the delivery of energy from electrode 88 up to,and including, cell necrosis. Cell injury can be accomplished as arelatively simple medical procedure with local anesthesia. In oneembodiment, cell injury proceeds to a depth of approximately 1-4 mm fromthe surface of the mucosal layer of sphincter 16 or that of an adjoininganatomical structure.

Referring now to FIGS. 18A, 18B, 18C and 18D, mapping electrodes 22, RFelectrodes 88 and/or apertures 64 may be distributed in a variety ofpatterns along expandable mapping assembly 20 or basket assembly 50 tofacilitate mapping and in order to produce a desired placement andpattern of lesions 14. Typical electrode (both mapping and RF varieties)and aperture distribution patterns include, but are not limited to, aradial distribution 104 (refer to FIG. 18A), a longitudinal distribution105 (refer to FIG. 18B), a spiral distribution 106 (refer to FIG. 18C)and a combination of longitudinal and radial distributions 107 (refer toFIG. 18D). It will be appreciated that other combinations, patterns andgeometries for electrode and aperture placement, may also be suitable.These electrodes may be cooled as described hereafter.

FIG. 19 is a flow chart illustrating one embodiment of the procedure forusing sphincter mapping and treatment apparatus 10. In this embodiment,sphincter mapping and treatment apparatus 10 is first introduced intothe esophagus under local anesthesia. Sphincter mapping and treatmentapparatus 10 can be introduced into the esophagus by itself or through alumen in an endoscope (not shown), such as disclosed in U.S. Pat. Nos.5,448,990 and 5,275,608, incorporated herein by reference, or similaresophageal access devices known to those skilled in the art. Basketassembly 50 is expanded as described herein. This serves to temporarilydilate the LES or sufficiently to efface a portion of or all of thefolds of the LES. In an alternative embodiment, esophageal dilation andsubsequent LES fold effacement can be accomplished by insufflation ofthe esophagus (a known technique) using gas introduced into theesophagus through shaft lumen 36, or an endoscope or similar esophagealaccess device as described above. Once treatment is completed, basketassembly 50 is returned to its predeployed or contracted state andsphincter mapping and treatment apparatus 10 is withdrawn from theesophagus. This results in the LES returning to approximately itspretreatment state and diameter. It will be appreciated that the aboveprocedure is applicable in whole or part to the treatment of othersphincters in the body.

As discussed previously, controller 24 and electropotential map 27 areused by the physician to diagnose abnormalities and pathologies withinsphincter 16 and adjoining structures. More specifically, they are usedto identify gastric electrical signals 17 and electrical events thatinclude depolarization, contraction and repolarization. Referring now toFIG. 20, this information is used by the physician to determine targettreatment sites 12 in the LES or adjoining anatomical structures thatare acting as electrical foci 108 or electrically conductive pathways109 for aberrant electrical signals 111 causing abnormal or otherwiseinappropriate relaxation of the smooth muscle of the LES or othersphincter 16. These targeted treatment sites 12 are then treated asdescribed herein so as to create lesions 14 which disrupt, block orotherwise prevent the generation and transmission of sufficient aberrantelectrical signals 111 to cause relaxation of the LES or other sphincterwall 26.

A variety of other diagnostic methods can be employed as an adjunct tosurface mapping of sphincter wall 26. These method include, but are notlimited to, the following: (i) visualization of the interior surface ofthe esophagus via an endoscope or other viewing apparatus inserted intothe esophagus, (ii) visualization of the interior morphology of theesophageal wall using ultrasonography to establish a baseline for thetissue to be treated; and, (iii) impedance measurement to determine theelectrical conductivity between the esophageal mucosal layers andsphincter mapping and treatment apparatus 10.

In one embodiment of the invention, impedance measurement is used as atool to locate the position of the nerve during either the diagnostic ortreatment phases of the procedure. In these and related embodiments, thephysician uses an impedance sensor 140 (described herein) positioned onone of electrodes 22, 88 and 90 or mapping assembly 20 to locate theposition of the nerve 8 to be ablated, and/or used as a conductivepathway for the delivery of energy to a selected gastric treatment site12. Specifically, nerve 8, 8′ is located by a decrease in measuredtissue impedance relative to a non-nerve portion of tissue. During orafter the delivery of energy to nerve 8, 8′ the ablation of the selectednerve can be monitored, quantified or titrated through the use of tissueimpedance measurement.

In related embodiments, a similar technique can be used to locate avagus nerve 8″ or other nerve 8, 8′, 8″ that is desired to be protectedduring the treatment phase of the procedure. Further, during thedelivery of energy to the treatment site 12, sensor 140 the can bepositioned at or adjacent the nerve to be protected to monitor nerveimpedance levels during the treatment of energy. Sensor 140 is coupledto a control system described here in. If the impedance level at or nearnerve 8 exceeds a predetermined value, the delivery of energy toelectrode 88 or 90 is shut off or decreased by the control system forthe position.

In the treatment phase of the procedure, the delivery of energy totreatment site 12 can be conducted under feedback control, manually orby a combination of both. Feedback control (described herein) enablessphincter mapping and treatment apparatus 10 to be positioned andretained in the esophagus during treatment with minimal attention by thephysician. RF electrodes 88 can be multiplexed in order to treat theentire targeted treatment site 12 or only a portion thereof. Feedbackcan be included and is achieved by the use of one or more of thefollowing methods: (i) visualization, (ii) impedance measurement, (iii)ultrasonography, (iv) temperature measurement; and, (v) sphinctercontractile force measurement via manometry. The feedback mechanismpermits the selected on-off switching of different RF electrodes 88 in adesired pattern, which can be sequential from one electrode 88 to anadjacent electrode 88, or can jump around between non-adjacent RFelectrodes 88. Individual RF electrodes 88 are multiplexed andvolumetrically controlled by controller 24.

The area and magnitude of cell injury in the LES or sphincter 16 canvary. However, it is desirable to deliver sufficient energy to thetargeted treatment site 12 to be able to achieve tissue temperatures inthe range of 55-95° C. and produce lesions 14 at depths ranging from 1-4mm from the interior surface of the LES or sphincter wall 26. Typicalenergies delivered to the esophageal wall include, but are not limitedto, a range between 100 and 50,000 joules per electrode 88. It is alsodesirable to deliver sufficient energy such that the resulting lesions14 have a sufficient magnitude and area of cell injury to cause aninfiltration of lesion 14 by fibroblasts 110, myofibroblasts 112,macrophages 114 and other cells involved in the tissue healing process(refer to FIG. 21). As shown in FIG. 22, these cells cause a contractionof tissue around lesion 14, decreasing its volume and, or altering thebiomechanical properties at lesion 14 so as to result in a tightening ofLES or sphincter 16. These changes are reflected in transformed lesion14′ shown in FIG. 19B. The diameter of lesions 14 can vary between 0.1to 4 mm. It is preferable that lesions 14 are less than 4 mm in diameterin order to reduce the risk of thermal damage to the mucosal layer. Inone embodiment, a 2 mm diameter lesion 14 centered in the wall of thesmooth muscle provides a 1 mm buffer zone to prevent damage to themucosa, submucosa and adventitia, while still allowing for cellinfiltration and subsequent sphincter tightening on approximately 50% ofthe thickness of the wall of the smooth muscle (refer to FIG. 23).

From a diagnostic standpoint, it is desirable to image the interiorsurface and wall of the LES or other sphincter 16, including the sizeand position of created lesions 14. It is desirable to create a map ofthese structures which can be inputted to controller 24 and used todirect the delivery of energy to treatment site 12. Referring to FIG.24, this can be accomplished through the use of ultrasonography (a knownprocedure) which involves the use of an ultrasound power source 116coupled to one or more ultrasound transducers 118 that are positioned onexpandable mapping assembly 20 or basket assembly 50. An output isassociated with ultrasound power source 116.

Each ultrasound transducer 118 can include a piezoelectric crystal 120mounted on a backing material 122 that is in turn, attached toexpandable mapping assembly 20 or basket assembly 50. An ultrasound lens124, fabricated on an electrically insulating material 126, is mountedover piezoelectric crystal 120. Piezoelectric crystal 120 is connectedby electrical leads 128 to ultrasound power source 116. Each ultrasoundtransducer 118 transmits ultrasound energy into adjacent tissue.Ultrasound transducers 118 can be in the form of an imaging probe suchas Model 21362, manufactured and sold by Hewlett Packard Company, PaloAlto, Calif. In one embodiment, two ultrasound transducers 118 arepositioned on opposite sides of expandable mapping assembly 20 or basketassembly 50 to create an image depicting the size and position of lesion14 in selected sphincter 16.

It is desirable that lesions 14 are predominantly located in the smoothmuscle layer of selected sphincter 16 at the depths ranging from 1 to 4mm from the interior surface of sphincter wall 26. However, lesions 14can vary both in number and position within sphincter wall 26. It may bedesirable to produce a pattern of multiple lesions 14 within thesphincter smooth muscle tissue in order to obtain a selected degree oftightening of the LES or other sphincter 16. Typical lesion patternsshown in FIGS. 25A-D include, but are not limited to, (i) a concentriccircle of lesions 14 all at fixed depth in the smooth muscle layerevenly spaced along the radial axis of sphincter 16, (ii) a wavy orfolded circle of lesions 14 at varying depths in the smooth muscle layerevenly spaced along the radial axis of sphincter 16, (iii) lesions 14randomly distributed at varying depths in the smooth muscle, but evenlyspaced in a radial direction; and, (iv) an eccentric pattern of lesions14 in one or more radial locations in the smooth muscle wall.Accordingly, the depth of RF and thermal energy penetration sphincter 16is controlled and selectable. The selective application of energy tosphincter 16 may be the even penetration of RF energy to the entiretargeted treatment site 12, a portion of it, or applying differentamounts of RF energy to different sites depending on the condition ofsphincter 16. If desired, the area of cell injury can be substantiallythe same for every treatment event.

In other embodiments shown in FIGS. 25E-G, lesions 14 are configured toproduce an area of electrical block 19 (also called blockage area 19 orarea 19) to a myoelectric or gastric signal 17, particularly a signalsuch as a gastric arrythimia 17′ causing a TLSER. The area of electricalblock is achieved by delivering sufficient energy to make the tissuecomprising all or a portion of areas 19 nonconducting. This can beaccomplished by heating the tissue sufficiently to denature proteins,destroy cell membrane, dehydrate/dessicate the tissue or otherwisealtering its physically properties. Blockage area 19 can also beachieved by delivering sufficient energy to damage or destroy a nervepathway within area 19 or a mechanical or chemo receptor 9, 9′.

In various embodiments, blockage area 19 can be placed by the physicianin a number of locations including the cardia, fundus, angle of his, LESand esophagus. The placement of area 19 in the cardia can includepositioning lesions 14 and blockage area 19 in or along a nerve pathwaywithin the cardia or fundus. In still another related embodiment, area19 comprises a lesion 14 placed within or along an afferent nerve 8′leading from a mechano or chemo receptor in the cardia or fundus to theanother area of the cardia, or LES (see FIG. 25F). In one preferredembodiment area 19 is placed within the cardia and blocks gastricsignals 17 from the fundus or cardia to the LES including signals 17from a mechano receptor or chemo receptor in the cardia or fundus to thecardia or LES (see FIG. 25G). Shapes for area 19 include but are notlimited to substantial linear, rectangular, circular, semicircular,annular, semi-annular and combinations thereof. In specific embodiments,area 19 can be comprise a linear or partially annular shaped positionedin the cardia (see FIG. 25G).

Referring to FIG. 26, it may be desirable to cool all or a portion ofthe area near the electrode-tissue interface 130 before, during or afterthe delivery of energy in order to reduce the degree and area of cellinjury. Specifically, the use of cooling preserves the mucosal layers ofsphincter wall 26 and protects, or otherwise reduces the degree of celldamage to cooled zone 132 in the vicinity of lesion 14. In oneembodiment the use of cooling is used to protect and/or minimize damageto a vagus nerve or other nerve 8″ associated with a swallowing reflex.Referring now to FIG. 27, this can be accomplished through the use of acooling solution 70 that is delivered by apertures 64 which is in fluidcommunication with shaft lumen 36 that is, in turn, in fluidcommunication with fluid reservoir 134 and a control unit 136, whoseoperation is described herein, that controls the delivery of the fluid.

Similarly, it may also be desirable to cool all or a portion of theelectrode 88. The rapid delivery of heat through electrode 88, mayresult in the build up of charred biological matter on electrode 88(from contact with tissue and fluids e.g., blood) that impedes the flowof both thermal and electrical energy from electrode 88 to adjacenttissue and causes an electrical impedance rise beyond a cutoff value seton RF power source 56. A similar situation may result from thedesiccation of tissue adjacent to electrode 88. Cooling of the electrode88 can be accomplished by cooling solution 70 that is delivered byapertures 64 as described previously. Referring now to FIG. 28,electrode 88 may also be cooled via a fluid channel 138 in electrode 88that is in fluid communication with fluid reservoir 134 and control unit136.

As shown in FIG. 29, one or more sensors 140 may be positioned adjacentto or on electrode 88 for sensing the temperature of sphincter tissue attreatment site 12. More specifically, sensors 140 permit accuratedetermination of the surface temperature of sphincter wall 26 atelectrode-tissue interface 130. This information can be used to regulateboth the delivery of energy and cooling solution 70 to the interiorsurface of sphincter wall 26. In various embodiments, sensors 140 can bepositioned at any position on expandable mapping assembly 20 or basketassembly 50. Suitable sensors that may be used for sensor 140 include:thermocouples, fiber optics, resistive wires, thermocouple IR detectors,and the like. Suitable thermocouples for sensor 140 include: T type withcopper constantene, J type, E type and K types as are well known thoseskilled in the art.

Temperature data from sensors 140 are fed back to control unit 136 andthrough an algorithm which is stored within a microprocessor memory ofcontrol unit 136. Instructions are sent to an electronically controlledmicropump (not shown) to deliver fluid through the fluid lines at theappropriate flow rate and duration to provide control temperature at theelectrode-tissue interface 130 (refer to FIG. 27).

The reservoir of control unit 136 may have the ability to control thetemperature of the cooling solution 70 by either cooling the fluid orheating the fluid. Alternatively, a fluid reservoir 134 of sufficientsize may be used in which the cooling solution 70 is introduced at atemperature at or near that of the normal body temperature. Using athermally insulated reservoir 142, adequate control of the tissuetemperature may be accomplished without need of refrigeration or heatingof the cooling solution 70. The flow of cooling solution 70 iscontrolled by control unit 136 or another feedback control system(described herein) to provide temperature control at theelectrode-tissue interface 130.

A second diagnostic phase may be included after the treatment iscompleted. This provides an indication of LES tightening treatmentsuccess, and whether or not a second phase of treatment, to all or onlya portion of the esophagus, now or at some later time, should beconducted. The second diagnostic phase is accomplished through one ormore of the following methods: (i) visualization, (ii) measuring theimpendance, (iii) ultrasonography, (iv) temperature measurement, (v)measurement of LES tension and contractile force via manometry or (vi)mapping/measuring the frequency of gastric myoelectric activityincluding normal slow frequency waves, and gastric arrhythmias 17′including tachygastrias and bradygastrias. In the latter case, theclinician can use the quantitative analysis of gastric arrhythmias (e,gfrequency, signal amplitude) 17′ as both an indication of a TLSER and asmeans to titrate treatment and establish a clinical endpointparticularly in the case when doing gastric nerve ablation or creatingareas of electrical block to pathways causing a TLSER. The detection andanalysis of gastric arrhythmias 17′ can be made using signal processingmeans described herein. The second diagnostic phase can also includestimulation to evoke a swallowing reflex using a stimulationdevice/means described herein to assure that the swallowing reflex andassociated nerves are still functional.

In one embodiment, sphincter mapping and treatment apparatus 10 iscoupled to an open or closed loop feedback system. Referring now to FIG.30, an open or closed loop feedback system couples sensor 346 toenergy/power source 392. In this embodiment, electrode 314 is one ormore RF electrodes 314 and power source 392 is an RF generator.

The temperature of the tissue, or of RF electrode 314 is monitored, andthe output power of energy source 392 adjusted accordingly. Thephysician can, if desired, override the closed or open loop system. Amicroprocessor 394 (also called controller 394 which can be the same ascontroller 24) can be included and incorporated in the closed or openloop system to switch power on and off, as well as modulate the power.The closed loop system utilizes microprocessor 394 to serve as acontroller to monitor the temperature, adjust the RF power, analyze theresult, refeed the result, and then modulate the power. Morespecifically, controller 394 governs the power levels, cycles, andduration that the radio frequency energy is distributed to theindividual electrodes 314 to achieve and maintain power levelsappropriate to achieve the desired treatment objectives and clinicalendpoints. Controller 394 can also in tandem, govern the delivery ofcooling fluid and, if desired, the removal of aspirated material.Microprocessor 394 can be integral to or otherwise coupled to powersource 392. The controller 394 can include an input/output (I/O) device394′. The I/O device 394′ allows the physician to input control andprocessing variables, to enable the controller to generate appropriatecommand signals. The I/O device 394′ also receives real time processingfeedback information from one or more sensors associated with theoperative element (as will be described later), for processing by thecontroller 394, e.g., to govern the application of energy and thedelivery of processing fluid. The I/O device 394′ may also include auser interface or graphical user interface (GUI), to graphically presentprocessing information to the physician for viewing or analysis. Asdiscussed herein, controller 394 can also be coupled to a fluid deliveryapparatus and/or an aspirating apparatus.

With the use of sensor 346 and the feedback control system a tissueadjacent to RF electrode 314 can be maintained at a desired temperaturefor a selected period of time without causing a shut down of the powercircuit to electrode 314 due to the development of excessive electricalimpedance at electrode 314 or adjacent tissue as is discussed herein.Each RF electrode 314 is connected to resources which generate anindependent output. The output maintains a selected energy at RFelectrode 314 for a selected length of time.

Current delivered through RF electrode 314 is measured by current sensor396. Voltage is measured by voltage sensor 398. Impedance and power arethen calculated at power and impedance calculation device 400. Thesevalues can then be displayed at user interface and display 402. Signalsrepresentative of power and impedance values are received by acontroller 404.

A control signal is generated by controller 404 that is proportional tothe difference between an actual measured value, and a desired value.The control signal is used by power circuits 406 to adjust the poweroutput in an appropriate amount in order to maintain the desired powerdelivered at respective RF electrodes 314.

In a similar manner, temperatures detected at sensor 346 providefeedback for maintaining a selected power. Temperature at sensor 346 isused as a safety means to interrupt the delivery of energy when maximumpre-set temperatures are exceeded. The actual temperatures are measuredat temperature measurement device 408, and the temperatures aredisplayed at user interface and display 402. A control signal isgenerated by controller 404 that is proportional to the differencebetween an actual measured temperature and a desired temperature. Thecontrol signal is used by power circuits 406 to adjust the power outputin an appropriate amount in order to maintain the desired temperaturedelivered at the sensor 346. A multiplexer can be included to measurecurrent, voltage and temperature, at the sensor 346, and energy can bedelivered to RF electrode 314 in monopolar or bipolar fashion.

Controller 404 can be a digital or analog controller, or a computer withsoftware. When controller 404 is a computer it can include a CPU coupledthrough a system bus. This system can include a keyboard, a disk drive,or other non-volatile memory systems, a display, and other peripherals,as are known in the art. Also coupled to the bus is a program memory anda data memory.

User interface and display 402 includes operator controls and a displayand may include a GUI interface as discussed herein. Controller 404 canbe coupled to imaging systems including, but not limited to, ultrasound,CT scanners, X-ray, MRI, mammographic X-ray and the like. Further,direct visualization and tactile imaging can be utilized.

The output of current sensor 396 and voltage sensor 398 are used bycontroller 404 to maintain a selected power level at RF electrode 314.The amount of RF energy delivered controls the amount of power. Aprofile of the power delivered to electrode 314 can be incorporated incontroller 404 and a preset amount of energy to be delivered may also beprofiled.

Circuitry, software and feedback to controller 404 result in processcontrol, the maintenance of the selected power setting which isindependent of changes in voltage or current, and is used to change thefollowing process variables: (i) the selected power setting, (ii) theduty cycle (e.g., on-off time), (iii) bipolar or monopolar energydelivery; and, (iv) fluid delivery, including flow rate and pressure.These process variables are controlled and varied, while maintaining thedesired delivery of power independent of changes in voltage or current,based on temperatures monitored at sensor 346.

Referring now to FIG. 31, current sensor 396 and voltage sensor 398 areconnected to the input of an analog amplifier 410. Analog amplifier 410can be a conventional differential amplifier circuit for use with sensor346. The output of analog amplifier 410 is sequentially connected by ananalog multiplexer 412 to the input of A/D converter 414. The output ofanalog amplifier 410 is a voltage which represents the respective sensedtemperatures. Digitized amplifier output voltages are supplied by A/Dconverter 414 to microprocessor 394. Microprocessor 394 may be a type68HCII available from Motorola. However, it will be appreciated that anysuitable microprocessor or general purpose digital or analog computercan be used to calculate impedance or temperature.

Microprocessor 394 sequentially receives and stores digitalrepresentations of impedance and temperature. Each digital valuereceived by microprocessor 394 corresponds to different temperatures andimpedances. Calculated power and impedance values can be indicated onuser interface and display 402. Alternatively, or in addition to thenumerical indication of power or impedance, calculated impedance andpower values can be compared by microprocessor 394 to power andimpedance limits. When the values exceed predetermined power orimpedance values, a warning can be given on user interface and display402, and additionally, the delivery of RF energy can be reduced,modified or interrupted. A control signal from microprocessor 394 canmodify the power level supplied by energy source 392.

FIG. 32 illustrates a block diagram of a temperature and impedancefeedback system that can be used to control the delivery of energy totissue site 416 by energy source 392 and the delivery of coolingsolution 70 to electrode 314 and/or tissue site 416 by flow regulator418. Energy is delivered to RF electrode 314 by energy source 392, andapplied to tissue site 416. A monitor 420 ascertains tissue impedance,based on the energy delivered to tissue, and compares the measuredimpedance value to a set value. If the measured impedance exceeds theset value, a disabling signal 422 is transmitted to energy source 392,ceasing further delivery of energy to RF electrode 314. If the measuredimpedance is within acceptable limits, energy continues to be applied tothe tissue.

The control of cooling solution 70 to electrode 314 and/or tissue site416 is done in the following manner. During the application of energy,temperature measurement device 408 measures the temperature of tissuesite 416 and/or RF electrode 314. A comparator 424 receives a signalrepresentative of the measured temperature and compares this value to apre-set signal representative of the desired temperature. If the tissuetemperature is too high, comparator 424 sends a signal to a flowregulator 418 (connected to an electronically controlled micropump, notshown) representing a need for an increased cooling solution flow rate.If the measured temperature has not exceeded the desired temperature,comparator 424 sends a signal to flow regulator 418 to maintain thecooling solution flow rate at its existing level.

This specification discloses various catheter-based systems and methodsfor treating dysfunction of sphincters and adjoining tissue regions inthe body. The systems and methods are particularly well suited fortreating these dysfunctions in the upper gastrointestinal tract, e.g.,in the lower esophageal sphincter and adjacent structures of the stomachsuch as the cardia. The disclosed systems and methods are alsoapplicable for use in treating other dysfunctions elsewhere in the body,which are not necessarily sphincter-related. For example, the variousaspects of the invention have application in procedures requiringtreatment of hemorrhoids, or incontinence, or restoring compliance to orotherwise tightening interior tissue or muscle regions. The systems andmethods that embody features of the invention are also adaptable for usewith systems and surgical techniques that are not necessarilycatheter-based. Furthermore, this specification is not intended to beexhaustive or to limit the invention to the precise forms disclosed.Obviously, many modifications and variations will be apparent topractitioners skilled in this art.

In another embodiment shown in FIG. 33, apparatus 10 can be coupled to asignal processing system 500 which comprises a signal processor 501 thatis integral to or otherwise couped to a controller 504. Signalprocessing means 501 in turn can be coupled to data/signal storagedevice 510 (also called memory resources 510) and signal comparitormeans 520. Signal processor 501 is configured to take time domainbioelecectric signals/waveforms 517 detected by electrodes 514, (such asmyoelectric or gastric signals 17 including those corresponding to orotherwise indicative of a TLESR) and convert them into frequency domainsignal 517′ in order to obtain information which can be displayed as awaveform indicative of the frequency of TLSERs or other myo/neurogastric event, such as a peristaltic wave, stomach contraction,swallowing reflex. The output signal 517′ of signal processor 501 can becoupled to and/or displayed on user interface 402. Signal processor 501can also be used to calculate other wave related functions such as powerspectral density and the like. Controller 504 serves to control the dataexchange/handshake (both analog and digital) between signal processor504, comparitors 520, and data storage device 510. Signal processor 501or controller 504 can output signal 517′ in either digital or analogform. In various embodiments controller 504 can be a mircroprocesser orapplication intergrated circuit (ASIC) which can include but is notlimited to having intergral: processors, data bus, ROM, A/D converters,video processor, math processor, and input/output channels. In relatedembodiments, signal processing means 501 can be one or moremicroprocessors or integrated circuits 502 with electronically stored orembedded instructions sets or programs 503 for performing a mathematicaltransform (including a fourier or fast fourier transform (including adiscrete FFT) or other wavelet transform function known in the art) toconvert a time domain signal 517 (which can also be gastric signal 17)to a frequency domain signal 517′, or vica versa. Processor 501 can alsoinclude but is not limited to having an integral data bus, ROM, A/Dconverter, video processor, math processor and input/output channels. Invarious embodiments, signal processor 501 or controller 504 can be acommercially available spectrum analyzer such as that made by theHewlett Packard Corporation or a commercially available microprocessorsuch as an Intel® Pentium® or Pentium III® series, or a Motorolla® PowerPC® series microprocessor. Processor 501 can be coupled to or haveintegral memory resources 505 which can be a Read Only Memory (ROM) chipcontaining stored or otherwise embedded programming for performingvarious signal processing functions including but not limited to fouriertransforms, wavelet functions, filtering (e.g. high and low passfiltering) and signal averaging and the like.

In a related embodiment shown in FIG. 34, a signal stimulation means 530can be coupled to signal processor 501. Signal stimulation means 530generates a selectable electrical signal/output 535 sufficient toproduce a TLESR, swallowing reflex, peristaltic wave or relatedmyo/neuro esophageal or gastric event. Additionally signal stimulationmeans 530 can be configured to produce any number of evoked potentialsor motor evoked potentials known in the art. In various embodiments,signal stimulation means 530 can be a commercially available medicalelectrical power supply such as DC or AC power supply available from theHewlett Packard® Corporation, or a nerve stimulating device availablefrom Danmeter A/S (Odense, Denmark) such as the Elfameter or one of theNeuro-Diagnostic product line available from the Medtronic® Corporation(Minneapolis, Minn.). A stimulating electrode 522 is electricallycoupled to stimulation means 530 and can be the same as mappingelectrode 22 or treatment electrode 22. In another embodiment,stimulating electrode 522 can be a transdermal electrode 523 placed onthe abdomen epidermal layer overlying the LES or nearby. In thisembodiment signal stimulation means 530 can is configured for producinga transdermal stimulating signal of sufficient amplitude and frequencyfor producing TLESR transdermally. Stimulation means 530 can be coupledto user interface 402 which can have user selected switching capabilitybetween in vivo and transdermal stimulation configurations. In variousembodiments one electrode 522 can both be a mapping and receiveelectrode coupled to stimulation means 530 and signal comparitor means520 (in this case signal stimulation means includes a time gatingcapability/algorithm for alternatively putting electrode 522 in astimulating/transmitting mode and a mapping receiving mode. Forembodiments with multiple electrodes 522, electrodes 522 can bemultiplexed such that a portion are configured for stimulation andanother portion are configured for mapping. For transdermal stimulationembodiments, electrode 522 on the apparatus 10 can be used as thereceiving electrode or a separate transdermaly coupled electrode 523(coupled to signal processing means 501) can be employed. In oneembodiment transdermal receiving electrode 523 can be a plurality ofelectrodes 523′ placed in larger area on the abdomen. The use of aplurality of electrodes improves signal detection, sensitivity andacquisition capability of signal processing means 501 for TLESR andother aberrant gastric signals. For transdermal embodiments, transdermalmapping and receiving electrodes 522 and 523 can be silver-silverchloride transdermal electrodes well known in the medical electronicsart. In one transdermal embodiment, one or both of transdermalelectrodes 523 and signal processing means 501 can be components fromthe Digitrapper™ EGG System available from the Medtronic® Corporation(Minneapolis, Minn.).

In one embodiment depicted in FIG. 35, signal stimulation means 530 andsignal processing means 501 are configured, to induce and/or monitor thepresence of the swallowing reflex before, during or after the deliveryof energy to the treatment site 12. This and related embodiments allowfor the protection of a vagus 8″ or other nerve 8, 8′, 8″ involved orassociated in the swallowing reflex.

To facilitate such stimulation the stimulating electrode 522 canpositioned on catheter 18 so as to be located in the more proximal/upperportions 6′ of the esophagus 6 including the pharynx and oral cavity. Inone embodiment, stimulating electrode 522 can be positioned proximal tomapping or treatment electrode 22. This allows for simultaneousstimulation of the upper esophagus 6′ to produce a swallowing reflex orother myo-gastric event (e.g. perstaltic wave) while one or more of thefollowing are performed: i) observation (by endoscopic, visual or othermeans) in the esophagus or LES for the swallowing reflex and/or openingof the LES, ii) mapping/sensing of the swallowing reflex, TLSER or othermyo-gastric event and iii) delivery of energy to treatment site 12 inthe LES 6 or other upper GI site. In other embodiments, stimulatingelectrode 522 can be positioned anywhere along the length of catheter 18including basket assembly 20. In these and related embodiments, thesignal stimulating electrode 522 can be used to evoke a swallowingreflex before or during the delivery of treatment to assure theintegrity of swallowing reflex and related nerves and then subsequentlyafterward treatment to assure the same.

The foregoing description of a preferred embodiment of the invention hasbeen presented for purposes of illustration and description. It is notintended to be exhaustive or to limit the invention to the precise formsdisclosed. Obviously, many modifications and variations will be apparentto practitioners skilled in this art. It is intended that the scope ofthe invention be defined by the following claims and their equivalents.

1. An apparatus, comprising a treatment device including at least one ofa mapping electrode or a treatment electrode, the treatment device beingsized and configured for introduction into at least a portion of atissue region comprising at least one of a sphincter, a lower esophagealsphincter, a stomach, a cardia or a fundus; means for stimulating thetissue region to produce a transient relaxation of at least a portion ofone of the sphincter, the lower esophageal sphincter, the stomach, thecardia or the fundus; means coupled to the treatment device foridentifying a portion of one of the sphincter, the lower esophagealsphincter, the stomach, the cardia or the fundus causing the transientrelaxation; and means coupled to the treatment device for deliveringenergy from the the mapping electrod or the treatment electrode to treatthe portion of one the sphincter, the lower esophageal sphincter, thestomach, the cardia or the fundus causing the transient relaxation. 2.The apparatus of claim 1, wherein the means for stimulating includes oneof an electrical stimulation, a mechanical stimulation, a stretchstimulation or a chemical stimulation.
 3. The apparatus of claim 1,further comprising means for performing a post treatment stimulation onone of the sphincter, the lower esophageal sphincter, the stomach, thecardia or the fundus; and means for assessing an effectiveness oftreatment in preventing the transient relaxation.
 4. The apparatus ofclaim 1, wherein the means for stimulating includes one of an externalstimulation device or an internal stimulation device, wherein theexternal stimulation device is positionable on the skin near the stomachor wherein the internal stimulation device is positionable in theportion of one the sphincter, the lower esophageal sphincter, thestomach, the cardia or the fundus.
 5. The apparatus of claim 4 whereinthe means stimulating includes one of an internal stimulation or atransdermal stimulation.
 6. An apparatus comprising a treatment devicehaving at least one of a mapping electrode or a treatment electrode, thetreatment device being sized and configured for introduction into atleast a portion of a tissue region comprising at least one of asphincter, a lower esophageal sphincter, a stomach, a cardia or afundus; means coupled to the treatment device for detecting anelectrical activity causing a transient relaxation of at least a portionof the sphincter, the lower esophageal sphincter, the stomach, thecardia or the fundus; means coupled to the treatment device fordelivering energy to treat the electrical activity; and means coupled tothe treatment device for mapping the tissue region after the treatmentto assess the effectiveness of the treatment.
 7. An apparatus forcomprising a treatment device having at least one of a mapping electrodeor a treatment electrode, the treatment device being sized andconfigured for introduction into at least a portion of one of sphincter,a lower esophageal sphincter, a stomach, a cardia or a fundus; means fordetecting a bioelectric activity causing a transient relaxation of atleast a portion of the sphincter, the stomach, the cardia or the fundus;and means for delivering energy from the treatment delivery device totreat the bioelectric activity; the treatment device comprising a basketassembly including a first and a second arm, the basket assembly beingcoupled to an elongated member and having a deployed and a non-deployedconfiguration; an inflatable member coupled to the elongated member andpositioned in an interior of the basket assembly, the inflatable memberbeing coupled to an inflation lumen, the inflatable member having adeployed stare and a non-deployed state, wherein in the deployed statethe inflatable member expands the basket assembly to the basket assemblydeployed configuration; a first energy delivery device positionable inthe first arm and advanceable from the first arm to a selected treatmentsite; and a second energy delivery device positionable in the second armand advanceable from the second arm to a selected treatment site; atleast one of the first and second energy delivery device adapted beingto adapted to deliver RF energy to a treatment site in one of thesphincter, the lower esophageal sphincter, the stomach, the cardia orthe fundus to at least partially ablate one of a nerve pathway, anafferent pathway, a electrical pathway, a mechanoreceptor pathway or achemoreceptor pathway.